Post-Disaster Intervention Procedure and Techniques Available for Psychosocial Workers to Assist Survivors

 

                                                                                                                 Raquel E. Cohen MD, MPH

 

Overview of Lecture

 

Description:  Introduces post-disaster intervention techniques and procedures

Purpose:  To review the scope and application of assistance guidelines

Content:  Defines the different procedures available to workers

Learning objectives: The worker will be able to acquire knowledge so as to choose the techniques that help survivors. What are the guidelines that give support to assist the survivors? What techniques are available?

 

Post-Disaster Techniques

 

Techniques available in disaster are defined as active interactions whose aims are to promote, complement and reinforce healthy functions and adaptive behavior of the survivor. Although expressions of empathy are helpful, care must be exercised not to reinforce or reward the “victim” role. Care should be taken not to interfere with psychological defenses, which the survivor needs during the initial period post-disaster. Establishing a relationship may be difficult in the initial period because the survivor often has distorted thinking due to high anxiety and cognitive blurring. They may be defensive, guarded and overwhelmed. Once established the relationship the worker can offer options in solving problems and can help the survivor by suggesting options in solving problems so as to find the most feasible way of living day by day.

 

The worker needs to be aware that the survivor is going to face different experiences as the community is reorganizing and as individuals continue to return to function.  Each of these phases will stimulate varying emotions and attitudes presenting a challenge to the worker who needs to ascertain what this changed behavior means.  What this increasing knowledge of behavior change in relation to time lapse indicates is that, intervention has to be "in sync" with the stage of crisis resolution after the disaster impact.

 

Post-Disaster Crisis Counseling

 

Post-Disaster crisis counseling is defined as "a mental health intervention technique useful in post-disaster events that seeks to restore the capacity of the individuals to cope with the stressful situation in which they find themselves. It has three aims: a) restoring capacity of the individual; b) reordering and organizing their new world; and c) assisting the victim to deal with the bureaucratic relief emergency program." The methodology to bring about these objectives varies according to the school of thought used by the worker. The reality circumstances mandate a short, flexible, creative adaptable approach compared to our usual organized, systematic clinical approach. This is an area where we continue to adapt clinical skills and modify our approaches as we learn from one disaster to the next. Differentiating variables like age, sex and cultural backgrounds taught us that both reactions and successful interventions differed in children, adults and the elderly of different cultures.

 

The goal of post-disaster psychological intervention is to alleviate a survivor’s emotional distress and/or cognitive disorganization and to suggest corrective action and offer appropriate information.  The worker can help survivors identify, interpret and normalize their overwhelming emotions, understand the normal reactive nature of feelings, and recover a sense of capability and hopefulness.

 

Goals in Helping Survivors

 

·                    To increase understanding of stress reactions so as to mitigate its effects

·                    To minimize the impact of trauma by increasing coping strategies

·                    To obtain and identify concrete types of help

·                    To develop and improve communication to aid in problem-solving skills and identify concrete types of help

·                    To develop and improve communication to aid in problem-solving skills

·                    To restore social coping and functioning within rapidly changing systems and disorganized social structures

·                    To support relationships with other survivors and staff of agencies providing health care, housing, and economic assistance

·                    To continue to foster coping skills and adaptation to post-disaster changes in the community so that survivors will be able to carry on and respond normally to an abnormal traumatic event and to the changes that have occurred in their lives and livelihood.

 

Post-disaster Crisis training –(based 0n Dr. Bernard Beitman  ‘LEARNING PSYCHOTHERAPY”)

 

Crisis Intervention Skills And Attitudes For Workers Post-Disaster: What are the goals of an effective training program?

 

We must select a limited number of skills that if effectively taught, will lead to effective crisis intervention. This objective requires careful selection from a wide variety of potential alternatives based on research and experience.  Trainers are encouraged to examine their own thinking and to apply critical attitudes to what they do and how they do it.  They learn to measure their effectiveness and respond to these evaluations with a sharpening of behavior and thinking.  It aims to teach workers to think flexibly at decision points in order to tailor intervention for specific survivors at specific points in the orifices of crisis resolution.

 

The training program is based upon 2 constructs:

 

The stages of crisis intervention – this is a process in a series of interventions-reactions proceeding through the passage of time.  This series of interactions can be divided into stages.  Each stage has goals, with mini-objectives within the process

 

STAGES OF CRISIS INTERVENTION THROUGH TIME ENGAGEMENT: build collaborative relations with survivor

 

PATTERN SEARCH: facilitating the ability to establish a working alliance by using interest of survivor

 

CHANGE: strategies to help the survivor return to  previous self

 

TERMINATION: attempt to separate from survivor and to  help maintain gains in coping and adapting post–disaster

 

BASIC ‘BOTTOM-LINE’ WORKERS BEHAVIOR AND VERBAL RESPONSES MODES AND INTERVENTION INTENTIONS (ATTITUDES)

 

First Stage: approval and support; allow the to tell their story; instill hope; reassure; offer information; permit reflection and self disclosure

 

Second Stage: open and closed-ended questions; Information gathering; cognitive focus; behavioral, feeling, relationship focus

 

Third Stage: clarification; education; reality testing; reinforcement and encouragement; offering insight connections

 

SECOND BASIC PRINCIPLE - OBSERVING OF SELF: this function needs to be developed in each crisis worker.  The worker needs to scrutinize how they think, feel and behave in their role as crisis intervenors and managers.

 

 

LIST OF WORKERS INTENTION

 

SET LIMITS – The array and extent of problems and needs of survivor are numerous and difficult to resolve.  This will necessitate careful considerations of priority and possibility of solutions.  Carefully weighing the solutions for feasibility and salience has to be considered at every step of the way.  Time phases will present differences in intensity, acuteness and emergency.  Give examples of situations and approaches.  Link to some real disasters

 

OBTAIN INFORMATION  --To get oriented to the situation in which the survivor finds himself there is a need of specific data while at the same time trying to establish a relationship by being sympathetic and conveying an attitude of caring.  Time is of the essence, both because of the number of survivors and their needs and the urgency to solve the needs of the survivor.  This necessitates a focused interrogatory interaction, a balance between support and data.

 

GIVE   -- How much expression of compassion, how far one goes to solve problems, how many resources one tries to obtain for the specific survivor is a question of skills and intuition plus experience in weighing ones own possibilities for success.

 

SUPPORT  - - Extending support to assist in problem solving is a continuous activity to help survivors.  Research has shown that this activity may be one of the most important for successful coping, problem solving and adaptation of the survivor as they proceed from the first traumatic moments through the process of mourning to finally accept the difficult new situation in which they will find themselves.

 

FOCUS  --Keeping a clear direction and objective of all the activities to assist a survivor is a difficult task due to the myriad possibilities and shifting situations in which both the worker and the survivor find themselves and their relations evolve.  Supervision of the workers activities is very helpful to assist the in this objective.

 

CLARIFY  - confusion, perplexity, unrealistic feelings and expectations are emotions of being a survivor.  They need assistance to check reality and plan for their future; this has to be done with sensitivity and skill.  Sometimes only giving part of news (death of a dear one, complete loss of a home) and in slow, small doses can the survivor process reality without recurring to unhealthy defenses.  Care must be taken to handle denial used by the survivor in order to keep their sanity.

 

HOPE   --A hopeful attitude should be conveyed to the survivor “together we will work and process the painful situation”.   This does not mean that one cheerfully or unrealistically offers solutions.

 

CATHARSIS  --Accepting the needs of the survivor to express painful feelings of guilt, regret, anger, sadness and crying will be part of allowing feelings to be shared.  It is important not to offer any explanation or efforts to assuage these expressions – sharing and listening in a comforting attitude is important for the survivor to share with their worker and not feel judged or belittled.

 

COGNITION  --The use of awareness, problem solving, options and reality checks is a constant technique of counseling and crisis intervention in disaster.  Methods of coping needs to be discussed and options using the best judgment for what is best for the survivor has to be explored

 

BEHAVIORS  - Documentation of worker and survivor behavior after a disaster will run the gamut of available possibilities of human reactions..  Expectable behavior of workers is part of the training necessary to work in this field.  It needs constant support, and supervision The behavior of survivors has been documented according to the phases post-disaster, age, sex, roles, ethnicity, socioeconomic status, religion etc (Use links to other documents)

 

SELF-CONTROL – This skill is necessary for workers who will experience all kinds of emotions, ranging from compassion to anger, shame and powerlessness Use link to documents)

 

FEELINGS –Every variety of human emotions are activated in workers and survivors in a disaster situation

 

INSIGHT—assisting survivors to gain insight into their NORMAL feelings within an ABNORMAL situation is one of the main assistance to survivors.  Due to the fact that the survivor’s reactions are unfamiliar and not socially consonant to their previous reactions they will self label as “crazy” or “sick”

 

CHANGE –everything in the life of a survivor will suffer some degree of change due to the impact of the catastrophic event.  With is change will come the realization of multiple loses so that mourning and coping with these events is a perennial activity of counseling the survivor.

 

REINFORCE  - there is a constant need to remind the survivor of their strength, capacity, skills, and resources to strengthen the behaviors of the survivor who feels defeated and powerless

 

RESISTANCE-DENIAL  --this defense is a primary defense during the initial period following the awareness of the impact produced by the disaster it is expectable and should be handled as a healthy capacity of the organism no become overwhelmed by the terrible situations in which they find themselves

 

 CHALLENGE  -working with survivors is one of the most challenging, difficult but rewarding professional activity.  Many workers expect this perception to last throughout their mission but it is important to realize that after several months in the field many of their tasks will be seen as routine.

 

RELATIONSHIP – the dramatic interaction between workers and survivors builds a different and special type of relationship.  It is important for the worker to guide this relationship in an ethical and professional manner

 

WORKERS NEEDS----Alert to BURN OUT; FEELINGS OF OBNIPOTENCE; PATRONIZING; PATERNALISM  INTERPERSONAL.  –Relationships with multiple individuals develop in the setting of working in a disaster.  Each one has specific characteristics, which should be well defined with clear objectives for the worker – Red Cross, FEMA, Civil Defense, Mental Health, Police, Medical Personnel, Funerary Directors, Shelter personnel, Coroner etc 

 

Consultation and Education

 

Consultation and Education are two areas of assistance that are being developed in addition to the direct face to face with intervention with the survivor. As emerging approaches in disasters increased the awareness that large number of non-mental health workers plus the public at large needed more information these two approaches have been added to programs of assistance. The model evolved using the consulting methods developed in community psychiatry (Caplan 1970) slowly evolved into the objectives of 1) increasing the capacity of the consultee to manage the survivor's planning 2) increase the knowledge of the consultee to deal with the organized agencies tasks addressing the needs of individuals after disasters. The lessons we learned, after acquiring the knowledge of the multilevel disaster assistance bureaucracy that emerges after a disaster impacts a community, had to do with the use of power and decision-making. In national declared emergency the power of the government representative is decisive. We learned that negotiating with them needed sensitive consultation techniques. The steps that all of us in community psychiatry had learned, that is, for example, to get permission and be invited as consultants, had to be carefully attended to. Suggesting methods to deal with victims, incorporating mental health values in decision making about a victim at times collided with other professional values, rules and regulations

 

Attention had to be given to the victim's need, the role of the emergency worker and the resources of the Disaster Assistance Program. Again, like crisis intervention had to be in "sync" with sequential stages of the victim's need, consultation to assist the consul tee’s responsibilities had to be attuned to the governmental agency needs according to sequential program activities.

 

Education

 

Opportunities for media communication and dissemination of mental health information present themselves following a disaster. The human story in disaster is very compelling and media professionals seek professionals to interview - at a rapid pace. In the midst of community crisis, the impact of these messages exerts a strong influence.

 

There are two specific areas that offer objectives to be accomplished by educational methods. One area deals with our knowledge of how the population has been psychologically affected by the trauma and the sequences of the stress response to the disaster. The other area is to offer knowledge of how the mental health system will respond and what we as professionals have to offer in post-disaster situations. Each of these areas has a) methods b) content and c) structure to disseminate knowledge.

 

The opportunity to disseminate knowledge to the public serves as a preventive method because it explains aspects of novel behavior and reactions that are unexpected and by being unfamiliar can potentiate further stress. Studies suggest that if a victim can derive an explanation for their reactions it will influence the person's adaptive response. If individuals are forewarned, they will anticipate their unusual expressions of emotions and then can accept them as appropriate under the circumstances.

 

Disseminating information about the mental health services, including consultation and education, facilitates the actual operations of mental health interventions.

 

Summary

 

Many of the skills used by professionals post-disaster are known to them but need to be adapted so as to assist the survivor who has been traumatized by the disaster, is not a patient and is not ill.  A small percentage of survivors will go on to show some signs of pathology over time and need to be referred to the appropriate services.